Maintained at 7.35-7.45 by Intracellular and extracellular buffering Respiratory mechanisms Renal mechanisms Arterial CO2 tension (PaCO2) Controlled by the CNS and respiratory system Plasma bicarbonate Controlled by the kidneys By retention or excretion of acid or alkali CLINICAL MANIFESTATIONS
LOW ARTERIAL PH
- generalized depressive effect
- drowsiness and lethargy - very low pH (<7.1) – coma - < 6.8 for any extended period – incompatible with life CLINICAL MANIFESTATIONS
HIGH BLOOD pH
- excitatory to the CNS
- irritability or tetany - serious arrhythmias - very high pH = convulsions - > 7.8 – incompatible with life pH Symptoms 7.80 Death Convulsions Arrhythmias Irritability 7.40 Normal Drowsiness Lethargy Coma 6.80 Death PaCO2
Usual steady state PaCO2 at 40 mmHg
Under-excretion causes hypercapnia Over-excretion produces hypocapnea Regulated primarily by neural respiratory factors and not by rate of CO2 production May be due to compensatory changes in response to a primary alteration in the plasma HCO3 HCO3
24 (22-26) Regulated by Reabsorption of filtered HCO3 Formation of titratable acid Excretion of ammonia in the urine Kidneys filter 4000 mmol per day 80-90% in the proximal tubule Acid-Base Disorders
Primary respiratory disturbances invoke
compensatory metabolic responses and vice versa in an attempt to drive pH to normal The degree of compensation can be predicted Any abnormal compensation define a mixed acid-base disturbance Acid-Base Disorders Acid-Base Disorders Causes
COPD Anxiety Neuromuscular diseases Pneumonia Chest wall disorders High altitude Obesity/OSA Pregnancy CNS depression Sepsis Drugs Drugs Anion gap
Measure of unmeasured anions in the blood
Major anions: Cl- and HCO3 Others: phosphates, sulfates and proteins Major Cation: Na Others: Ca, K, Mg Anion Gap: unmeasured anions – unmeasured cations (Na)- (Cl+HCO3) 8-10 mmol/L Compensatory Responses in Simple Acid-Base Disturbances
Metabolic Acidosis Limit
PCO2= (1.5 x HCO3) + 8 + 2 10 mmhg Metabolic Alkalosis Each mEq inc. in HCO3= 0.5-1.0 mmhg inc in PCO2 55 mmhg Acute Respiratory Acidosis HCO3 inc by 3-4 mEq/L 30 mmhg Acute Respiratory Alkalosis HCO3 dec by 2-4 mEq/L 18 mEq/L Chronic Respiratory Acidosis Each mEq inc in PCO2= 0.4 meq/L inc in HCO3 45mEq/L Chroinc Respiratory Alkalosis Each mEq dec in Pco2 = 0.5 mEq dec in Hco3 12-15mEq/L PRIMARY PROBLEM
RESPIRATORY
40 – ACTUAL PCO2 X 100
40
METABOLIC
24 – ACTUAL HCO3 X 100
24 EXAMPLE 1 pH - 7.28 PaCO2 - 60 mmHg HCO3 - 22 mEq/L Solution: Expected HCO3= 24 + (Actual PaCO2 – Desired PaCO2) x 0.1 24 + (60-40) x 0.1 24 + 2 26 Acute Respiratory acidosis, uncompensated if ph is between 7.35-7.45 24 + (Actual PCO2 – Desired PCO2) x 0.4 24 + (60-40) x 0.4 24 + (20 x 0.4) 24 + 8 32 Chronic Respiratory Acidosis, uncompensated EXAMPLE 2 pH - 7.49 PaCO2 - 32 mmHg HCO3 - 26 mEq/L Solution: Expected HC03 = 24 –(Desired PaCo2 – Actual PaCo2) x 0.2 24- (40-32) x 0.2 24- (8 x 0.2) 24- 1.6 22.4 Acute Respiratory Alkalosis, uncompensated if ph is between 7.35-7.45 24- (40-32) x 0.4 24- (8 x 0.4) 24- 3.2 20.8 Chronic Respiratory Alkalosis, uncompensated Example 3 pH: 7.50 PaCo2: 36 Hco3: 32 Solution: Expected PaCo2: Actual HCo3 + 15 32 + 15 47 or [(Desired PaCo2 – Actual PaCo2) x 0.75] + 40 [(40-36) x 0.75] + 40 (4x0.75)+ 40 3+40 44 Uncompensated Metabolic Alkalosis Example 4 pH: 7.10 PaCo2: 45 HCo3: 14 Solution: Expected PaCo2: (1.5 x HCO3) + 8 (1.5 x 14) + 8 21+8 29 0r Actual HC03 + 15 14 + 15 29 Uncompensated Metabolic Acidosis CLASSIFICATION PaO2 (mmHg) Hyperoxemia >100 Normoxemia 80 – 100 Mild Hypoxemia 60 – 79 Moderate Hypoxemia 45 – 59 Severe Hypoxemia < 45 QUANTIFYING PULMONARY DYSFUNCTION Indices of Oxygenation
1. pO2 2. P/F ratio 3. O2 saturation 4. aADO2 – difference in O2 in the alveolus and the arterial blood (alveolar-arterial O2 gradient or difference) pAO2 = 713 (FiO2) – pCO2 0.8 aADO2 = pAO2 – paO2 Normal ≤ 20 Oxygenation
Expected pO2 at room air:
For age ≤ 60 y.o. = 80-100 For age > 60 y.o. = 80 - # of years above 60 eg. 70 y.o. = 80-10 = 70
Ideal PO2 for age: 103.5 - 0.42(age)
Oxygenation
At Room Air: - Compare actual pO2 to expected pO2 Actual < Expected = HYPOXEMIC Actual > Expected = NON-HYPOXEMIC
On supplemental O2: - Expected P/F ratio (pO2/FIO2) For age ≤ 60 y.o.: 400-500 For age > 60 y.o.: 400 – (age above 60 x 5) eg. 70 y.o.: 400 – (10 x 5) = 350 FiO2 per nasal cannula: = (O2 in L/min) x 4 + 20 eg. O2 at 2 lpm = 2 x 4 + 20 = 28%
Actual P/F ratio:
P/F = paO2 (actual from ABG) FiO2 (expressed in decimal) FiO2 Requirement
Room air = 0.21
Nasal cannula= # of liters x 4 + 20/100
Face mask = # LPM x 10 – 20
ET = # LPM x 10 OXYGENATION RATIO
PULMONARY OXYGENATION STATUS RATIO Normal 400 – 500 Moderate Pulmonary 200 – 399 dysfunction Substantial Pulmonary < 200 dysfunction 4 MECHANISMS
Blood passing from the right side of the heart to
the left side of the heart without being exposed to alveolar oxygen Anatomic or capillary in nature Does not respond to administration of supplemental oxygen Capillary Shunting
Alveolar consolidation (filling with fluid)
Collapse Causes: ARDS, left-sided heart failure, pneumonia, atelectasis Pulmonary edema – single greatest cause of severe, absolute capillary shunting Anatomic Shunting
Congenital cardiovascular abnormalities
Persistent fetal circulation Relative Shunting
Most common V/Q perfusion mismatch Perfusion in excess of ventilation Good PaO2 response to small increments of oxygen therapy Uneven distribution of ventilation secondary to increased pulmonary secretions COPD Diffusion defects
Anatomic impedance to oxygen transfer in the
lungs, due to a thickened alveolar-capillary membrane Responds to oxygen therapy Can be included to relative shunting PHYSIOLOGIC SHUNTING
Percentage of the venous blood that remains
unoxygenated after traveling from the right side of the heart to the left side of the heart I. (alveolar) PAO2 = 713 (FiO2) – pC02/0.8
= 285- 43 = 242 II = I (O2 for age/PO2) = 242 (85.86/156) = 242 x .55 = 133 III = II [(PCO2/0.8) x 100]/ 713 = 133 ( 43 x 100) x 100/713 = 24 Exercise
Age: 79 pH: 7.32 PCO2: 28 PO2: 101 HCO3: 14 FIO2: 2 lpm via NC Metabolic Acidosis, uncompensated, non-hypoxemic, with overcorrected FIO2 at 2lpm Nc Expected PCO2= (1.5 x O2 for Age HCO3) + 8 103.5 –(0.42 x 79) (1.5 x 14) + 8 103.5 – 33.18 21+ 8 70.32 29 P/F ratio= 101/.28 360 Expected P/F ratio 400- (19x5) 400 – 95 305 New FIO2
I = 713 (FIO2)- PCO2/0.8
=713 (.28) -35 =1.99.64-35 = 164 II =I (O2 for age/PO2) = 164 x 0.69 =113.16 III = II x [(PCO2/0.8) x 100]/713 = 113.16 x (35 x 100)/713 = 20. 77 Exercise
Age: 54 pH: 7.53 PCO2: 45.2 HCO3: 37.8 PO2: 78 FIO2: 8l FM Metabolic Alkalosis, uncompensated with hypoxemia, uncorrected @ 8LPM via N.C Expected PCO2= Actual PF ratio= 78/0.60 HCO3 + 15 130 37.8 + 15 O2 for age=103.5-(.42 x 52.8 or age) [(Desired HCO3-Actual 80.82 HCO3)x0.75] + 40 10.35 + 40 50.35 New FIO2
I = 713 (FIO2) – PCO2/0.8
= 713 (.60)- 56.6 = 427- 56.5 = 371 II = I (O2 for age/po2) = 371 x 1.03 = 382 III = III + [(Pco2/0.8) x 100]/ 713 = 382 + (56.6 x 100)/ 713 = 61.5 Exercise
= 713 (0.28) – 117.625 = 82.015 II = I (O2 for age/PO2) = 82.015 (74.94/60) = 102 III = III + [(PCO2/0.8) x 100] /713 = 102 + (117.625) x 100/ 713 = 30 Henderson-Hasselbalch equation: to determine if acid is chronic or acute
A. H+ = 24x PCO2/ HCO3
= 24 x 94.1/40.4 = 55.68 B. Delta H+= [H+] – Desired PCO2 = 55.68 – 40 = 15.68 C. Delta PaCO2= Actual PCO2- Desired PCO2 = 94.1 - 40 = 54.1 D. Delta [H+]/Delta PCO2 = 15.68/54.1 = 0.3 = Acute on top of chronic Interpretation
0.3 – 0.7 < 0.3 chronic hypercapnia > 0.7 acute hypercapnia 0.3 -0.7 acute on top of chronic Exercise
Age: 32 pH: 7.41 pCO2: 36.7 pO2: 56 HCO3: 23.5 FIO2: 4l NC Normal Acid base balance with Hypoxemia uncorrected @ 4l via NC
O2 for age=103.5- (0.24x32) PF ratio= 56/0.36 103.5-13.44 155 90.06 New FIO2
I = 713 (FIO2) – PCO2/.8
= 713 (0.36) – 45.875 = 256.68.-45.875 = 210.805 II = I (O2 for age/PO2) = 210.805 x 1.6-8 = 338.97 III = II [PCO2/0.8 )x 100]/713 = 338.97 (45.875 x 100)/ 713 = 53.97 HCO3 Deficit
Metabolic acidosis 18 to 20 (desired)-actual HCO3 x (0.4 to 0.6) x weight Half of computed is given SIVP then half as 24 hour drip Repeat ABG post correction
Example: pH 7.18 PCO2 27 HCO3 9 Thank you for your attention
